Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and Health Survey

Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and... Abstract Aim The aim of this study is to examine the prevalence of bottle feeding (BF) among children aged 0–23 months and factors associated with BF in Namibia. Methods Data from Namibia 2013 Demographic Health Survey were used for the study. The study covered last-born alive children aged 0–23 months, making up 1926 mother–baby pairs. Chi-square tests and binary logistic regression were used to test for association between BF and related factors. Results Prevalence of BF in Namibia was 35.7%. In the multivariate analysis, the following factors were significantly associated with increased risk of BF: working mothers, hospital delivery, increasing child age, higher mother’s educational status, higher wealth quintile and urban residence. Conclusion To achieve a substantial decrease in bottle usage rate in Namibia, breastfeeding promotion programmes should target all mothers but especially those at risk of BF highlighted in the study. bottle-feeding, Namibia, breastfeeding, usage INTRODUCTION Breastfeeding is beneficial for mother–baby pairs, families and the society, as it has immunological, nutritional, developmental, socio-economic and environmental benefits [1–5]. Optimal breastfeeding includes early initiation of breastfeeding, i.e within 1 h of birth, exclusive breastfeeding for the first 6 months of life and continued breastfeeding for up to 2 years or beyond with appropriate complementary feeding beginning at 6 months [6]. In Namibia, not all children are exclusively breastfed in the first 6 months of life, with only about 49% of children aged <6 months being exclusively breastfed [7]. After 6 months of age, it is recommended that any liquids given to the child should be fed by cup rather than by bottle, avoiding the use of bottle with nipple [8]. However, over the past few years, an increase in bottle feeding (BF) has been observed in developing countries [9]. Feeding a child using a bottle with a nipple is not encouraged because it endangers the child’s health and survival through contamination, and interferes with breastfeeding establishment. Also, BF is associated with a greater risk of short pregnancy interval [10]. The adverse effects of BF are profound in developing countries owing to lack of access to clean water as well as unhygienic surroundings [11]. In addition, the prevalence of low-quality and unsuitable bottles and teats in these countries further aggravate the situation [12]. Existing literature indicates that the following factors affect BF: mother’s working status, maternal education, institutional delivery, wealth index, child age, parity and aggressive marketing and promotion of breast-milk substitutes [9, 12–14]. In Namibia, there is a paucity of studies based on nationally representative samples examining the determinant of BF, and this research fills this gap. The study purpose is twofold. First, to determine the prevalence of BF in Namibia, and second, to examine factors associated with BF in the aforementioned country. An understanding of the factors influencing BF in Namibia will aid the country’s policy makers in framing policies and programmes that would decrease BF, which in turn will contribute in reducing child morbidity and mortality. MATERIALS AND METHODS Sample The study used data from the 2013 Demographic Health Survey (DHS) conducted in Namibia. All women aged 15–49 years who were either permanent residents of the households or women present in the households on the night before the survey were eligible to be interviewed during the survey. Further details of the sampling and data collection method can be found in the DHS manual [7]. Analysis for this study was restricted to last-born children who were alive and aged <2 years at the time of the survey. The total sample size was 1926 mother–baby pairs. After accounting for sample weights, this corresponded to a sample size of 1815 mother–baby pair. Operational definition(s) In the DHS woman's questionnaire, mothers were asked, ‘Did (child name) drink anything from a bottle with a nipple yesterday or last night?’ [7]. The outcome variable ‘BF’ was defined as drinking anything from a bottle with nipple yesterday or past night and was expressed as a dichotomous variable with category 1 for children who drank anything from a bottle with nipple yesterday or past night and Category 0 for children who did not. The explanatory variables were chosen based on previous studies [9, 12–14] and included mother’s age, mother’s education, mother’s occupation, place of residence, birth rank, delivery type and place, sex of child, postnatal check within 2 months of birth, child age and wealth index, which was categorized into lowest (poorest), second (poorer), middle, fourth (richer) and highest (richest) wealth quintile; the index was constructed using household asset data via a principal components analysis. Statistical analysis Sample characteristics are given as unweighted case numbers and percentages, whereas BF distribution by different explanatory variables were reported as weighted percentages based on women’s individual weights. Chi-square tests were performed to evaluate the association of the explanatory variables with BF, and variables significant at the 0.25 level were included in the multivariate analysis and assessed by binary logistic regression. Adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were reported. The multivariate analysis accounted for the sample design and sample weight using Statistical Package for Social Sciences (SPSS) complex sample analysis method (SPSS version 24). Ethics The survey was reviewed and approved by the inner city fund (ICF) institutional review board, which offered technical support for the survey and by the National Ethics Committee of Namibia. Permission to use and analyse the data set was obtained by registering the study on the Demographic and Health Survey (DHS) website. RESULTS Socio-demographic characteristics of study participants Table 1 shows the socio-demographic characteristics of the study participants. The highest proportion of mothers belonged to the age group 20–34 years (69.9%), and a greater percentage of mothers resided in rural areas (Table 1). Table 1 Socio-demographic characteristics of study participants Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Note.aUnweighted. Table 1 Socio-demographic characteristics of study participants Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Note.aUnweighted. The overall prevalence of BF in Namibia was 35.7%. According to regions, the highest prevalence of BF was observed in Khomas (56.8%), Erongo (56.1%) and Karas (56.1%), while the lowest prevalence of BF was reported in Ohangwena (19.3%) (Fig. 1). Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Unadjusted associations with BF Table 2 shows the unadjusted association of explanatory variables with BF. BF was significantly higher among the following categories: mothers with secondary and above educational status, working mothers, mothers belonging to the highest wealth quintile, urban mothers, mothers with second to third birth order, mothers with health facility-caesarean delivery, children with post-natal check within 2 months of birth and children in the age group 6–11 months (Table 2). Table 2 Rates of BF among children aged 0–23 months Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Note. aWeighted. Table 2 Rates of BF among children aged 0–23 months Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Note. aWeighted. Multivariate analysis Table 3 shows the adjusted associations between BF and explanatory variables. The odds of BF was significantly higher for mothers with secondary and above educational status as compared with mothers with primary and below educational status. In addition, mothers who were working had 51% higher odds of BF as compared with mothers who were not working. When compared with the lowest wealth quintile, mothers who belonged to higher wealth quantile had higher odds of BF. Furthermore, mothers who resided in urban areas had 67% higher odds of BF as compared with mothers who resided in rural areas. Women who had health facility-vaginal delivery or health facility-caesarean delivery were more likely to bottle feed their children as compared with women who delivered at home. According to the study findings, children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. Table 3 Factors associated with BF in children aged 0–23 months Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. Table 3 Factors associated with BF in children aged 0–23 months Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. DISCUSSION Namibia has an overall BF prevalence of 35.7% among children aged 0–23 months. The prevalence of BF showed variability among regions, with region like Khomas (56.8%) reporting higher prevalence of BF and region like Ohangwena (19.3%) recording lower prevalence. The overall prevalence of BF among children aged 0–23 months in Namibia was much higher than what was observed in Tanzania and Pakistan among children aged 0–23 months. In Tanzania, the authors reported a prevalence of 3.2% for BF, while in Pakistan, Hazir et al. [15, 16] reported a BF prevalence of 31.2%. The difference in BF prevalence between Namibia and the aforementioned countries might be attributed to country’s difference in socio-demographic and economic status and such differences at individual, household and community levels may play a role. The reported prevalence of BF in Namibia suggests the need for policy makers and public health practitioners in Namibia to focus more on achieving a considerable decrease in the prevalence of BF in their country. In this study, mothers working status influenced BF. Working mothers were more likely to bottle feed as compared with their non-working counterpart. This finding is in consonance with studies done in Bangladesh and Ethiopia [17, 18] and reflect the need for policy makers to consider improving maternity leave situation of working mothers. There is also a need to ensure that working mothers are provided breastfeeding breaks and breastfeeding spaces [19]. It is generally assumed that mothers who deliver at health facilities are more likely to get information on breastfeeding at the health facility; however, in the current study, mothers who delivered in a hospital had higher risk of BF as compared with mothers who delivered at home. This result is in conformity with a study done by Hazir et al. [16] and indicates the need for a reassessment of baby-friendly hospital management method in Namibia. In the literature, there are studies indicating that marketing of infant formula with a focus on the health system might contribute to the increase in bottle usage among mothers who had institutional delivery [20–22]. Associations have been found between child age and the use of artificial nipple [23, 24]. In the current study, older children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. The increase in the use of BF as the child age progress might be explained by the fact that bottle use is associated with water, tea and processed milk intake, which are commonly given as the child age progress [24]. Another factor that was associated with bottle usage rate was mother’s educational status. BF was significantly higher among mothers with higher educational status; this finding is in consonance with studies done by Hazir et al. [16] and Boerme et al. [9] that showed that increasing level of education was significantly associated with higher levels of bottle use. The study finding with regards mother’s educational status and BF reflect the fact that higher mother’s educational status does not necessarily mean increased awareness and understanding of the advantages of breastfeeding. Wealth index was another significant predictor of BF. Mothers belonging to higher wealth quintiles were more likely to bottle feed than mothers in the lowest wealth quintiles; this is in line with previous studies that found higher socio-economic status to be associated with BF [16, 17]. This finding may be explained by the fact that mothers belonging to the higher wealth quintile may have easy access to expensive breastfeeding alternatives, which might indirectly influence their choice to bottle feed. In public health literature, there are studies indicating an association between breastfeeding practices and place of residence [25–27]. In the current study, urban mothers were more likely to bottle feed as compared with their rural counterpart. This finding is consistent with previous studies that have shown urban mothers to be at a greater risk of BF as compared with rural mothers [9, 16]. A plausible explanation for this result could be that most urban mothers were more likely to be from families with higher socio-economic status as compared with their rural counterparts and that may have facilitated their access to breast-milk substitutes and information on breast-milk substitute; furthermore, most urban mothers are likely to have paid employment and the pressure to return to work after maternity leave might result in bottle usage [15, 28]. This study is not without some limitations. The data were based on a cross-sectional study as such is subject to recall limitation; in addition, caution must be exercised in making causal influence of the identified determinants of BF. Culturally, in Namibia, families are organized along kinship lines, with children being cared for by multiple members of the extended family. Future studies looking at factors such as family structures, cultural practice and ethnicity will help in enriching the knowledge on BF in Namibia. The study strength lies in the nationally representative sample and the adjustments made for sampling design during the analysis. CONCLUSION To decrease BF prevalence in Namibia, interventions should include breastfeeding promotion through Information, Education and Communication targeting all mothers, but most especially mothers belonging to at-risk subgroups of BF highlighted in this study. Also, part of the interventions should include training of health workers on Infant and Young Child Feeding (IYCF) counselling, promotion of safe and healthy IYCF practices and proper enforcement of the International Code of Marketing of Breast-milk Substitutes. ACKNOWLEDGEMENTS The author would like to acknowledge Measure DHS for making available the 2013 NDHS data set for this study. REFERENCES 1 Anatolitou F. Human milk benefits and breastfeeding . J Pediatr Neonat Individual Med 2012 ; 1 : 11 – 18 . 2 Sankar MJ , Sinha B , Chowdhury R , et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis . Acta Paediatr 2015 ; 104 : 3 – 13 . http://dx.doi.org/10.1111/apa.13147 Google Scholar CrossRef Search ADS PubMed 3 Ip S , Chung M , Raman G , et al. Breastfeeding and maternal and infant health outcomes in developed countries . Evid Rep Technol Assess 2007 ; 153 : 1 – 186 . 4 Victora CG , Horta BL , de Mola CL , et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil . Lancet Glob Health 2015 ; 3 : e199 – 205 . Google Scholar CrossRef Search ADS PubMed 5 Chowdhury R , Sinha B , Sankar MJ , et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis . Acta Paediatr Suppl 2015 ; 104 : 96 – 113 . http://dx.doi.org/10.1111/apa.13102 Google Scholar CrossRef Search ADS 6 Victora CG , Bahl R , Barros AJD ; for The Lancet Breastfeeding Series Group , et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect . Lancet 2016 ; 387 : 475 – 90 . http://dx.doi.org/10.1016/S0140-6736(15)01024-7 Google Scholar CrossRef Search ADS PubMed 7 The Namibia Ministry of Health and Social Services (MoHSS) and ICF International . The Namibia Demographic and Health Survey 2013 . Windhoek, Namibia; Rockville, MD : The Namibia Ministry of Health and Social Services (MoHSS) and ICF International , 2014 . 8 WHO . Infant and young child feeding: a tool for assessing national practices, policies and programmes . Geneva, Switzerland : WHO , 2003 . 9 Boerma JT , Rutstein SO , Sommerfelt AE , et al. Bottle use for infant feeding in developing countries: data from the demographic and health surveys: has the bottle battle been lost? J Trop Pediatr 1991 ; 37 : 116 – 20 . Google Scholar CrossRef Search ADS PubMed 10 Huffman SL , Lamphere BB. Breastfeeding performance and child survival. In: Mosley WH , Chen LC (eds). Child Survival: Strategies for Research . Cambridge: Cambridge University Press, 1984 , 93 – 116 . 11 Jason JM , Niebugr P , Marks JS. Mortality and infectious disease associated with infant feeding practices in developing countries . Pediatrics 1984 ; 74 : 702 – 27 . Google Scholar PubMed 12 Shamim S , Jamalvi SW , Naz F. Determinants of bottle use amongst economically disadvantaged mothers . J Ayub Med Coll Abbottabad 2006 ; 18 : 48 – 51 . Google Scholar PubMed 13 Buccini Gdos S , Benício MH , Venancio S. Determinants of using pacifier and bottle feeding . Rev Saude Publica 2014 ; 48 : 571 – 82 . Google Scholar CrossRef Search ADS PubMed 14 Okeyo NO , Konyole SO , Okeyo LA , et al. Characteristics of caregivers and households practicing bottle-feeding in Kisumu east district . African Journal of Food, Agriculture, Nutrition and Development 2012 ; 12 : 6868 – 79 . 15 Victor R , Baines SK , Agho KE , et al. Determinants of breastfeeding indicators among children less than 24 months of age in Tanzania: a secondary analysis of the 2010 Tanzania Demographic and Health Survey . BMJ Open 2013 ; 3 : e001529 . doi: 10.1136/bmjopen-2012-001529. Google Scholar CrossRef Search ADS PubMed 16 Hazir T , Akram DS , Nisar YB , et al. Determinants of suboptimal breast-feeding practices in Pakistan . Public Health Nutr 2013 ; 16 : 659 – 72 . http://dx.doi.org/10.1017/S1368980012002935 Google Scholar CrossRef Search ADS PubMed 17 Mihrshahi S , Kabir I , Roy SK , et al. Determinants of infant and young child feeding practices in Bangladesh: secondary data analysis of Demographic and Health Survey 2004 . Food Nutr Bull 2010 ; 31 : 295 – 313 . http://dx.doi.org/10.1177/156482651003100220 Google Scholar CrossRef Search ADS PubMed 18 Gebriel A. Determinant of weaning practices . Ethiop J Health Dev 2000 ; 14 : 183 – 9 . http://dx.doi.org/10.4314/ejhd.v14i2.9919 Google Scholar CrossRef Search ADS 19 UNICEF . Improving breastfeeding, complementary foods and feeding practices. https://www.unicef.org/nutrition/index_breastfeeding.html (26 June 2017, date last accessed). 20 Pries AM , Huffman SL , Mengkheang K , et al. Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding . Maternal & Child Nutrition 2016 ; 12 : 38 – 51 . http://dx.doi.org/10.1111/mcn.12271 Google Scholar CrossRef Search ADS PubMed 21 Hanif R , Khalil E , Sheikh A , et al. Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals . J Pak Med Assoc 2008 ; 60 : 881 – 6 . 22 Winikoff B , Laukaran VH. Breastfeeding and bottle feeding controversies in the developing World: evidence from a study in four countries . Soc Sci Med 1989 ; 29 : 859 – 68 . http://dx.doi.org/10.1016/0277-9536(89)90085-3 Google Scholar CrossRef Search ADS PubMed 23 Aarts C , Hornell A , Kylberg E , et al. Breastfeeding patterns in relation to thumb sucking and pacifier use . Pediatrics 1999 ; 104 : e50. Google Scholar CrossRef Search ADS PubMed 24 Victora CG , Behague DP , Barros FC , et al. Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997 ; 99 : 445 – 53 . Google Scholar CrossRef Search ADS PubMed 25 Roberts GJ , Cleaton-Jones PE , et al. Breast and bottle feeding in rural and urban South African children . J Hum Nutr Diet 1995 ; 8 : 255 – 63 . http://dx.doi.org/10.1111/j.1365-277X.1995.tb00319.x Google Scholar CrossRef Search ADS 26 Dev K , Agarwal KN , Tewari IC , et al. Breast feeding practices in urban slum and rural areas of varanasi . J Trop Pediatr 1982 ; 28 : 89 – 92 . http://dx.doi.org/10.1093/tropej/28.2.89 Google Scholar CrossRef Search ADS PubMed 27 Senarath U , Siriwardena I , Godakandage SSP , et al. Determinants of breastfeeding practices: an analysis of the Sri Lanka Demographic and Health Survey 2006–2007 . Matern Child Nutr 2012 ; 8 : 315 – 29 . http://dx.doi.org/10.1111/j.1740-8709.2011.00321.x Google Scholar CrossRef Search ADS PubMed 28 Senarath U , Dibley MJ , Agho KE. Factors associated with nonexclusive breastfeeding in 5 East and Southeast Asian countries: a multilevel analysis . J Hum Lact 2010 ; 26 : 248 . http://dx.doi.org/10.1177/0890334409357562 Google Scholar CrossRef Search ADS PubMed © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and Health Survey

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Abstract

Abstract Aim The aim of this study is to examine the prevalence of bottle feeding (BF) among children aged 0–23 months and factors associated with BF in Namibia. Methods Data from Namibia 2013 Demographic Health Survey were used for the study. The study covered last-born alive children aged 0–23 months, making up 1926 mother–baby pairs. Chi-square tests and binary logistic regression were used to test for association between BF and related factors. Results Prevalence of BF in Namibia was 35.7%. In the multivariate analysis, the following factors were significantly associated with increased risk of BF: working mothers, hospital delivery, increasing child age, higher mother’s educational status, higher wealth quintile and urban residence. Conclusion To achieve a substantial decrease in bottle usage rate in Namibia, breastfeeding promotion programmes should target all mothers but especially those at risk of BF highlighted in the study. bottle-feeding, Namibia, breastfeeding, usage INTRODUCTION Breastfeeding is beneficial for mother–baby pairs, families and the society, as it has immunological, nutritional, developmental, socio-economic and environmental benefits [1–5]. Optimal breastfeeding includes early initiation of breastfeeding, i.e within 1 h of birth, exclusive breastfeeding for the first 6 months of life and continued breastfeeding for up to 2 years or beyond with appropriate complementary feeding beginning at 6 months [6]. In Namibia, not all children are exclusively breastfed in the first 6 months of life, with only about 49% of children aged <6 months being exclusively breastfed [7]. After 6 months of age, it is recommended that any liquids given to the child should be fed by cup rather than by bottle, avoiding the use of bottle with nipple [8]. However, over the past few years, an increase in bottle feeding (BF) has been observed in developing countries [9]. Feeding a child using a bottle with a nipple is not encouraged because it endangers the child’s health and survival through contamination, and interferes with breastfeeding establishment. Also, BF is associated with a greater risk of short pregnancy interval [10]. The adverse effects of BF are profound in developing countries owing to lack of access to clean water as well as unhygienic surroundings [11]. In addition, the prevalence of low-quality and unsuitable bottles and teats in these countries further aggravate the situation [12]. Existing literature indicates that the following factors affect BF: mother’s working status, maternal education, institutional delivery, wealth index, child age, parity and aggressive marketing and promotion of breast-milk substitutes [9, 12–14]. In Namibia, there is a paucity of studies based on nationally representative samples examining the determinant of BF, and this research fills this gap. The study purpose is twofold. First, to determine the prevalence of BF in Namibia, and second, to examine factors associated with BF in the aforementioned country. An understanding of the factors influencing BF in Namibia will aid the country’s policy makers in framing policies and programmes that would decrease BF, which in turn will contribute in reducing child morbidity and mortality. MATERIALS AND METHODS Sample The study used data from the 2013 Demographic Health Survey (DHS) conducted in Namibia. All women aged 15–49 years who were either permanent residents of the households or women present in the households on the night before the survey were eligible to be interviewed during the survey. Further details of the sampling and data collection method can be found in the DHS manual [7]. Analysis for this study was restricted to last-born children who were alive and aged <2 years at the time of the survey. The total sample size was 1926 mother–baby pairs. After accounting for sample weights, this corresponded to a sample size of 1815 mother–baby pair. Operational definition(s) In the DHS woman's questionnaire, mothers were asked, ‘Did (child name) drink anything from a bottle with a nipple yesterday or last night?’ [7]. The outcome variable ‘BF’ was defined as drinking anything from a bottle with nipple yesterday or past night and was expressed as a dichotomous variable with category 1 for children who drank anything from a bottle with nipple yesterday or past night and Category 0 for children who did not. The explanatory variables were chosen based on previous studies [9, 12–14] and included mother’s age, mother’s education, mother’s occupation, place of residence, birth rank, delivery type and place, sex of child, postnatal check within 2 months of birth, child age and wealth index, which was categorized into lowest (poorest), second (poorer), middle, fourth (richer) and highest (richest) wealth quintile; the index was constructed using household asset data via a principal components analysis. Statistical analysis Sample characteristics are given as unweighted case numbers and percentages, whereas BF distribution by different explanatory variables were reported as weighted percentages based on women’s individual weights. Chi-square tests were performed to evaluate the association of the explanatory variables with BF, and variables significant at the 0.25 level were included in the multivariate analysis and assessed by binary logistic regression. Adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were reported. The multivariate analysis accounted for the sample design and sample weight using Statistical Package for Social Sciences (SPSS) complex sample analysis method (SPSS version 24). Ethics The survey was reviewed and approved by the inner city fund (ICF) institutional review board, which offered technical support for the survey and by the National Ethics Committee of Namibia. Permission to use and analyse the data set was obtained by registering the study on the Demographic and Health Survey (DHS) website. RESULTS Socio-demographic characteristics of study participants Table 1 shows the socio-demographic characteristics of the study participants. The highest proportion of mothers belonged to the age group 20–34 years (69.9%), and a greater percentage of mothers resided in rural areas (Table 1). Table 1 Socio-demographic characteristics of study participants Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Note.aUnweighted. Table 1 Socio-demographic characteristics of study participants Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Characteristics Na %a Mother’s age (years)  15–19 212 11.0  20–34 1347 69.9  35 and above 367 19.1 Marital status  Never in a union/formerly in union/living with a man 1044 54.2  Currently in union/living with a man 882 45.8 Mother’s education  Primary and below 598 31.0  Secondary and above 1328 69.0 Mother’s occupation  Not working 1144 59.5  Working 780 40.5 Wealth quintile  Lowest 410 21.3  Second 444 23.1  Middle 437 22.7  Fourth 383 19.9  Highest 252 13.1 Place of residence  Urban 840 43.6  Rural 1086 56.4 Birth rank  1st birth rank 592 30.7  2nd–3rd birth rank 807 41.9  4th birth rank 527 27.4 Delivery type and place  Home 262 13.7  Health facility—vaginal delivery 1370 71.4  Health facility—caesarean section 287 15.0 Sex of child  Male 928 48.2  Female 998 51.8 Baby received postnatal check within 2 months of birth  Yes 965 50.3  No 955 49.7 Child’s age (months)  0–5 527 27.4  6–11 503 26.1  12–23 896 46.5 Note.aUnweighted. The overall prevalence of BF in Namibia was 35.7%. According to regions, the highest prevalence of BF was observed in Khomas (56.8%), Erongo (56.1%) and Karas (56.1%), while the lowest prevalence of BF was reported in Ohangwena (19.3%) (Fig. 1). Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Unadjusted associations with BF Table 2 shows the unadjusted association of explanatory variables with BF. BF was significantly higher among the following categories: mothers with secondary and above educational status, working mothers, mothers belonging to the highest wealth quintile, urban mothers, mothers with second to third birth order, mothers with health facility-caesarean delivery, children with post-natal check within 2 months of birth and children in the age group 6–11 months (Table 2). Table 2 Rates of BF among children aged 0–23 months Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Note. aWeighted. Table 2 Rates of BF among children aged 0–23 months Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Characteristics Had BF p value na %a Mother’s age (years)  15–19 60 30.5 0.147  20–34 458 35.8  35 and above 131 38.9 Marital status  Never in a union/formerly in union/living with a man 349 34.8 0.352  Currently in union/living with a man 299 36.9 Mother’s education  Primary and below 109 21.3 <0.001  Secondary and above 539 41.4 Mother’s occupation  Not working 296 28.3 <0.001  Working 352 46.0 Wealth quintile  Lowest 71 18.1 <0.001  Second 129 30.6  Middle 136 34.6  Fourth 153 43.5  Highest 158 62.5 Place of residence  Urban 408 48.9 <0.001  Rural 241 24.6 Birth rank  1st birth rank 217 37.9 0.002  2nd–3rd birth rank 296 38.2  ≥4th birth rank 135 28.8 Delivery type and place  Home 34 16.1 <0.001  Health facility—vaginal delivery 463 35.4  Health facility—caesarean delivery 150 51.7 Sex of child  Male 317 36.1 0.742  Female 331 35.4 Baby received postnatal check within 2 months of birth  Yes 359 38.5 0.012  No 288 32.8 Child’s age (months)  0–5 126 25.9 <0.001  6–11 250 50.8  12–23 272 32.5 Note. aWeighted. Multivariate analysis Table 3 shows the adjusted associations between BF and explanatory variables. The odds of BF was significantly higher for mothers with secondary and above educational status as compared with mothers with primary and below educational status. In addition, mothers who were working had 51% higher odds of BF as compared with mothers who were not working. When compared with the lowest wealth quintile, mothers who belonged to higher wealth quantile had higher odds of BF. Furthermore, mothers who resided in urban areas had 67% higher odds of BF as compared with mothers who resided in rural areas. Women who had health facility-vaginal delivery or health facility-caesarean delivery were more likely to bottle feed their children as compared with women who delivered at home. According to the study findings, children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. Table 3 Factors associated with BF in children aged 0–23 months Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. Table 3 Factors associated with BF in children aged 0–23 months Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Characteristics OR (95% CI) p value AOR (95% CI) p value Mother’s age (years)  15–19 Ref Ref  20–34 1.28 (0.88–1.86) 0.192 1.06 (0.70–1.60) 0.792  35 and above 1.46 (0.93–2.27) 0.098 1.43 (0.86–2.40) 0.169 Mother’s education  Primary and below Ref Ref  Secondary and above 2.62 (1.93–3.55) <0.001 1.54 (1.12–2.11) 0.007 Mother’s occupation  Not working Ref Ref  Working 2.15 (1.73–2.68) <0.001 1.51 (1.19–1.93) 0.001 Wealth quintile  Lowest Ref Ref  Second 1.99 (1.42–2.79) <0.001 1.46 (1.01–2.11) 0.043  Middle 2.39 (1.71–3.35) <0.001 1.50 (1.04–2.17) 0.031  Fourth 3.46 (2.45–4.88) <0.001 1.83 (1.23–2.72) 0.003  Highest 7.51 (4.99–11.30) <0.001 2.85 (1.76–4.63) <0.001 Place of residence  Urban 2.93 (2.30–3.73) <0.001 1.67 (1.26–2.22) <0.001  Rural Ref Ref Birth rank  1st birth rank 1.51 (1.12–2.03) 0.006 1.16 (0.79–1.70) 0.460  2nd–3rd birth rank 1.53 (1.13–2.06) 0.005 1.14 (0.80–1.61) 0.476  ≥4th birth rank Ref Ref Delivery place and type  Home Ref Ref  Health facility—vaginal delivery 2.87 (1.93–4.25) <0.001 1.66 (1.07–2.57) 0.023  Health facility—caesarean delivery 5.60 (3.51–8.94) <0.001 2.30 (1.37–3.88) 0.002 Baby received postnatal check within 2 months of birth  No Ref Ref  Yes 1.28 (1.02–1.62) 0.038 1.15 (0.91–1.44) 0.239 Child’s age (months)  0–5 Ref Ref  6–11 2.97 (2.19–4.03) <0.001 3.32 (2.37–4.63) <0.001  12–23 1.38 (1.06–1.80) 0.016 1.26 (0.94–1.70) 0.129 Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. DISCUSSION Namibia has an overall BF prevalence of 35.7% among children aged 0–23 months. The prevalence of BF showed variability among regions, with region like Khomas (56.8%) reporting higher prevalence of BF and region like Ohangwena (19.3%) recording lower prevalence. The overall prevalence of BF among children aged 0–23 months in Namibia was much higher than what was observed in Tanzania and Pakistan among children aged 0–23 months. In Tanzania, the authors reported a prevalence of 3.2% for BF, while in Pakistan, Hazir et al. [15, 16] reported a BF prevalence of 31.2%. The difference in BF prevalence between Namibia and the aforementioned countries might be attributed to country’s difference in socio-demographic and economic status and such differences at individual, household and community levels may play a role. The reported prevalence of BF in Namibia suggests the need for policy makers and public health practitioners in Namibia to focus more on achieving a considerable decrease in the prevalence of BF in their country. In this study, mothers working status influenced BF. Working mothers were more likely to bottle feed as compared with their non-working counterpart. This finding is in consonance with studies done in Bangladesh and Ethiopia [17, 18] and reflect the need for policy makers to consider improving maternity leave situation of working mothers. There is also a need to ensure that working mothers are provided breastfeeding breaks and breastfeeding spaces [19]. It is generally assumed that mothers who deliver at health facilities are more likely to get information on breastfeeding at the health facility; however, in the current study, mothers who delivered in a hospital had higher risk of BF as compared with mothers who delivered at home. This result is in conformity with a study done by Hazir et al. [16] and indicates the need for a reassessment of baby-friendly hospital management method in Namibia. In the literature, there are studies indicating that marketing of infant formula with a focus on the health system might contribute to the increase in bottle usage among mothers who had institutional delivery [20–22]. Associations have been found between child age and the use of artificial nipple [23, 24]. In the current study, older children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. The increase in the use of BF as the child age progress might be explained by the fact that bottle use is associated with water, tea and processed milk intake, which are commonly given as the child age progress [24]. Another factor that was associated with bottle usage rate was mother’s educational status. BF was significantly higher among mothers with higher educational status; this finding is in consonance with studies done by Hazir et al. [16] and Boerme et al. [9] that showed that increasing level of education was significantly associated with higher levels of bottle use. The study finding with regards mother’s educational status and BF reflect the fact that higher mother’s educational status does not necessarily mean increased awareness and understanding of the advantages of breastfeeding. Wealth index was another significant predictor of BF. Mothers belonging to higher wealth quintiles were more likely to bottle feed than mothers in the lowest wealth quintiles; this is in line with previous studies that found higher socio-economic status to be associated with BF [16, 17]. This finding may be explained by the fact that mothers belonging to the higher wealth quintile may have easy access to expensive breastfeeding alternatives, which might indirectly influence their choice to bottle feed. In public health literature, there are studies indicating an association between breastfeeding practices and place of residence [25–27]. In the current study, urban mothers were more likely to bottle feed as compared with their rural counterpart. This finding is consistent with previous studies that have shown urban mothers to be at a greater risk of BF as compared with rural mothers [9, 16]. A plausible explanation for this result could be that most urban mothers were more likely to be from families with higher socio-economic status as compared with their rural counterparts and that may have facilitated their access to breast-milk substitutes and information on breast-milk substitute; furthermore, most urban mothers are likely to have paid employment and the pressure to return to work after maternity leave might result in bottle usage [15, 28]. This study is not without some limitations. The data were based on a cross-sectional study as such is subject to recall limitation; in addition, caution must be exercised in making causal influence of the identified determinants of BF. Culturally, in Namibia, families are organized along kinship lines, with children being cared for by multiple members of the extended family. Future studies looking at factors such as family structures, cultural practice and ethnicity will help in enriching the knowledge on BF in Namibia. The study strength lies in the nationally representative sample and the adjustments made for sampling design during the analysis. CONCLUSION To decrease BF prevalence in Namibia, interventions should include breastfeeding promotion through Information, Education and Communication targeting all mothers, but most especially mothers belonging to at-risk subgroups of BF highlighted in this study. Also, part of the interventions should include training of health workers on Infant and Young Child Feeding (IYCF) counselling, promotion of safe and healthy IYCF practices and proper enforcement of the International Code of Marketing of Breast-milk Substitutes. ACKNOWLEDGEMENTS The author would like to acknowledge Measure DHS for making available the 2013 NDHS data set for this study. REFERENCES 1 Anatolitou F. Human milk benefits and breastfeeding . J Pediatr Neonat Individual Med 2012 ; 1 : 11 – 18 . 2 Sankar MJ , Sinha B , Chowdhury R , et al. 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Journal of Tropical PediatricsOxford University Press

Published: Nov 30, 2017

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